ClaimAuditor

The Challenge of Claim Audit

"Nobody gets audit right today, plans do the best they can." -- large employer The healthcare claims process is a 'payment' process and because it is a payment proces audit is a fundamental part of claims. More specifically, many employers groups, federal and state agencies, lines of business and the NCQA require audits. Generally accepted accounting principles also mandate them. Having the tools to properly and productively audit claims that pass thorugh the hundreds of steps, systems, and people that make up claims is a significant challenge.

ClaimAuditor: Designed to Audit Claims

ClaimAuditor is a turnkey claim auditing tool. It was designed to support the needs of claim auditing and recovery departments. Audit needs continue to grow in scope and complexity while many audit departments audit and report using home grown tools. ClaimAuditor is designed to make auditors more productive and the audit process more benefial in terms of identifying payment errors and expediting recoveries

• Increase Auditor Productivity. Auditing is hard work. The audit process includes an initial audit set up and sampling (number of claims, stratified, frequency,...), an auditor assignment (who should work on a particular audit), individual claim review, and audit reporting. Setting up a monthly stratified audit and assigning it to auditors requires about five minutes in ClaimAuditor. For many payers it can take weeks to set up a new audit. Other audit steps such as review and reporting are similarly burdensome in most payers. ClaimAuditor is designed to free your auditors to do what they're supposed to -- find and fix claims process and payment errors.
• Standardize Claim Reviews. Applying a standard set of claim review practices is difficult. There are many data elements, input documents (e.g. claim attachments) and process documents (e.g. provider contract) that need to be included. ClaimAuditor makes it easier to standardize these steps with a set of automated prompts and a post review checklist that helps individual auditors make sure critical audit steps are correctly completed.
• Increase Audit Transparency. Once complete, audits can be difficult to figure out. Questions such as what was audited (were adjusted claims included?) or which auditors worked on the audit should be a pro forma for every audit. Audits that can be easily checked and understood are audits whose results can be used to drive process and policy changes.
• Increase Payment Accuracy. ClaimAuditor helps you increase payment accuracy in three ways. First it makes it easier to identify the payment errors themselves. Second, the reporting tools make it easier to analyze errors across audits and periods to better identify error patterns and root causes. Third, the claim search tools enable auditors to identify appropriate claims for recovery.
• Increase Recoveries. Finding errors is the first step. Collecting the overpayments that resulted from those errors is the second step. ClaimAuditor has a set of tools to help identify and tag other claims with identified errors to facilitate the recovery process.

Innovation, Flexibility, and Scalabilty

How does the ClaimAuditor work? It works by combining two core data technologies with an easy to use web-based user interface. First it loads open and closed claims data each day and applies a set of business rules to each claim. (Would you like to see the rule used to determine duplicate claim lines?). Second, it loads the individual claim data into a search engine (claimfetch) that enables users to search on indivual and sets of claims (Would you like to see 100 random claims that were denied as duplicates for that provider?). These two technologies are then tied to rich and robost web interface that enables multiple auditors to audit and report simultaneously.